THE WRIST
Clinical examination of
the wrist
Ashley W Newton
David H Hawkes
Vijay Bhalaik
Abstract
Accurate clinical assessment of the wrist can be difficult, due to the
large number of structures that are found in a confined space,
which give rise to a range of pathologies. It is therefore essential
that clinicians develop a thorough and systematic technique of exam-
ination to elucidate the cause of the patient’s wrist symptoms. This
paper outlines key points for the clinical assessment of the symptom-
atic wrist. This is followed by an overview of the potential pathologies
in each anatomical wrist zone, their typical symptoms and the perti-
nent examination findings the surgeon should seek to elicit. Thinking
of the wrist as a series of five zones facilitates identification of the pa-
thology. The described zones are radialedorsal, radialevolar, ulnar
edorsal, ulnarevolar and central. Tips for the interpretation of each
test are also included, along with an assessment of the sensitivity
and specificity of relevant tests and its implications. Often, the better
the clinical examination, the more productive the radiological
examination.
Keywords carpus; clinical assessment; examination; wrist
Introduction
The wrist is a complex anatomical arrangement, with multiple
interconnected structures in a relatively confined space. This
can make identification of the pathology responsible for
particular symptoms potentially difficult. It is necessary to
adopt a systematic approach to examination in order to narrow
the wide differential diagnosis. This requires a sound knowl-
edge of not only wrist anatomy, but the potential pathologies
and the provocative tests which help delineate them from each
other.
This article will deal with general considerations concerning
systematic examination of the wrist, then explore common cau-
ses of wrist symptoms and how to examine for them. The focus is
on sub-acute and elective conditions in the adult.
Ashley W Newton MBChB MRes MRCS PGCTLCP FHEA Specialty
Registrar, Trauma and Orthopaedic Surgery, North West (Mersey)
Deanery, Health Education England, Liverpool, UK. Conflict of
interest: none declared.
David H Hawkes MBChB MPhil MRCS Specialty Registrar, Trauma and
Orthopaedic Surgery, North West (Mersey) Deanery, Health
Education England, Liverpool, UK. Conflict of interest: none
declared.
Vijay Bhalaik MBBS MRCS FRCS Consultant Hand and Upper Limb
Surgeon, Wirral University Teaching Hospital, Arrowe Park Hospital,
Wirral, UK. Conflict of interest: none declared.
ORTHOPAEDICS AND TRAUMA 31:4
General history
A focused history will guide clinical examination. Ask about
hand dominance, occupation, sporting level and previous in-
juries. There are four main symptoms that should be explored in
some detail: 1. pain; 2. stiffness; 3. weakness; 4. clicking.
Pain is important and enquiry should be made about its site
(radial, central or ulnar; dorsal or volar), onset (insidious,
following trauma), character (dull ache, sharp on movement),
radiation (forearm, hand), exacerbating factors (particular
movements), relieving factors (rest, analgesia), and severity
(preventing work or self-care). The location of the pain is a
strong guide towards the diagnosis, and this helps focus the
clinical examination. The most common site of pain for a variety
of pathologies is detailed in Figure 1.
General examination
Positioning
The examination should be conducted with the examiner sitting
directly opposite the patient (so the patient can be observed for
signs of discomfort) with a table between upon which the patient
can rest their elbow. This position facilitates comfort and allows
forearm rotation to be controlled (Figure 2). Both hands, wrists
and forearms need to be exposed to allow comparison with the
contralateral side.
The examination should then follow the standard orthopaedic
format of ‘look, feel, move’ followed by special/provocative
tests.
Inspection (look)
Look at the hand and wrist, paying particular attention to skin
condition, swellings, muscle atrophy and deformity. Specific
signs to seek on inspection are listed in Box 1. Diagnoses such as
rheumatoid arthritis should be obvious at this stage of the
examination.
Palpation (feel)
Elicit tenderness, instability, crepitus, and clicking by palpation.
Determine if masses are superficial or deep, fixed or mobile, hard
or fluctuant. The different zones for palpation are considered
later in this article in reference to each pathology and are sum-
marised in Box 2. It is important to consider the dorsal and volar
surface anatomy during palpation (Figure 3). Pulses of the radial
and ulnar artery are palpated and sensation in the distribution of
the median, ulnar, and superficial radial nerves is checked.
Range of motion (move)
The wrist has multiple points of articulation, which produce a
variety of movements including flexion, extension, radial and
ulnar deviation, pronation and supination which should be
compared with the contralateral side (Figure 4).
Flexion and extension originate from the radiocarpal and
midcarpal joints and loss of this motion suggests pathology in
these joints. Supination and pronation occur at the distal radio-
ulnar joint (DRUJ) and disease of this joint leads to decreased
rotation. In addition to assessing movements in isolation, a
useful measure of combined functional motion is the ‘dart
throwing motion’ (Figure 5).
237 Ó 2017 Elsevier Ltd. All rights reserved.
 THE WRIST

DORSAL
st
1 CMC joint arthritis Lunotriquetral instability
STT joint arthritis DRUJ osteoarthritis
Radial styloid arthritis DRUJ instability
De Quervain’s Tenosynovitis ECU tendonitis
Intersection syndrome ECU instability
Wartenberg syndrome
ECRL/ECRB tendonitis
CENTRAL
Midcarpal instability
Scapholunate dysfunction
RADIAL ULNAR
Keinbock’s disease
SLAC wrist
Carpal tunnel syndrome
st
1 CMC joint arthritis FCU tendonitis
FCR tendonitis Ulna nerve compression
Scaphoid non-union Pisotriquetral arthritis
Carpal tunnel syndrome TFCC tear
Ulnocarpal abutment

VOLAR

Figure 1 Wrist pathology listed by site of pain. CMC, carpometacarpal; DRUJ, distal radioulnar joint; ECRB, extensor carpi radialis brevis; ECRL,
extensor carpi radialis longus; ECU, extensor carpi ulnaris; FCR, flexor carpi radialis; FCU, flexor carpi ulnaris; SLAC, scapholunate advanced
collapse; STT, scaphotrapezial trapezoid; TFCC, triangular fibrocartilage complex.

Special tests
The numerous special tests for wrist pathology vary in their re-
ported sensitivity and specificity. No single test is completely
pathognomonic, hence several features must be interpreted in
the clinical context of each individual patient to arrive at a
diagnosis; a process of pattern recognition.
Whilst it is clearly evident clinicians should understand how
to correctly perform these special tests is it equally important to
have an understanding of the psychometric properties of each
test. Sensitivity describes the ability of a test to correctly identify
those patients with a particular condition. Conversely, specificity
refers to the ability of a test to correctly identify those without the
condition. A reminder about interpreting sensitivity and speci-
ficity is found in Box 3. A number of the tests relating to wrist
pathology have either a limited sensitivity or specificity and it is
clearly essential that we understand these limitations if the cor-
rect diagnosis is to be established.
Radialedorsal symptoms
Thumb carpometacarpal joint osteoarthritis
Osteoarthritis of the first carpometacarpal (CMC) joint e often
referred to as base of thumb arthritis e is a very common

Figure 2 Positioning for clinical examination of the wrist. The examiner sits opposite the
patient with a small arm table between them.

ORTHOPAEDICS AND TRAUMA 31:4 238 Ó 2017 Elsevier Ltd. All rights reserved.
 THE WRIST

other hand is used to stabilize the wrist. A positive result is pain,

Signs to look for on inspection with or without crepitus. The traction shift (subluxation-reloca-
tion) test is an alternative, which is performed by applying lon-
C Swelling, e.g. over extensor carpi ulnaris tendon, first extensor gitudinal traction to the thumb, followed by alternating volar and
compartment dorsal pressure to the base of the first metacarpal. This provokes
C Masses, e.g. ganglia, rheumatoid nodules subluxation and relocation of the joint and is positive if there is
C Deformity, e.g. radial deviation, Z thumb pain. Both of these tests are easy to perform and have high
C Scars, e.g. previous distal radius fixation, carpal tunnel release quoted specificity.
C Muscle wasting, e.g. thenar eminence, first dorsal interosseous Higher sensitivity has been reported for the adduction test. In
Box 1 the adduction test the patient places the affected hand on the
examination table with the elbow flexed 90 and the forearm in
neutral rotation. The examiner places his or her ipsilateral hand
Suggested order for palpation of the whole wrist such that the examiner’s thumb rests over the head of the thumb
metacarpal dorsally. The examiner’s contralateral hand supports
the ulnar side of the patient’s hand to maintain the patient’s wrist
Radial side: in a neutral position in order to prevent ulnar deviation of the
patient’s wrist. The examiner firmly directs an adduction force
C First carpometacarpal joint
downward onto the patient’s metacarpal head until the patient’s
C Scaphotrapezial trapezoid joint
thumb metacarpal lies parallel to the mid axis of the index
C Radial styloid
metacarpal or until a firm end point is reached (Figure 6). Pain at
C First extensor compartment
the first CMC joint represents a positive test.
C Second extensor compartment
Sensitivity and specificity estimates are detailed in Table 1.2,3
C Scaphoid
It is worth noting that point tenderness over the joint has both
C Flexor carpi radialis tendon
good sensitivity and specificity. Pitfalls in the examination of
base of thumb arthritis include inconsistent correlation between
Central clinical findings and radiological features, which may account for
some of the low reported sensitivity rates. A patient with severe
C Lunate
degenerative changes on radiographs may have little or no pain.
C Scapholunate joint
C Carpal tunnel STT joint arthritis
Patient’s with scaphotrapezial trapezoid (STT) joint arthritis
Ulnar side usually report a history of deep thenar eminence pain and base of
thumb pain. Test the patient’s dart throwing motion (see
C Hook of hamate Figure 5), which will often be painful and have reduced range.
C Pisotriquetral joint On examination, there is tenderness over the surface landmark of
C Lunotriquetral joint the joint, which is just distal and ulnar to the anatomical snuff
C Distal radioulnar joint box (Figure 3). The final stage of base of thumb arthritis is
C Ulnar soft spot pantrapezial arthritis (Eaton-Littler stage IV) in which the STT
C Extensor carpi ulnaris tendon joint is involved. As such the two conditions described above
C Flexor carpi ulnaris tendon commonly co-exist.
Palpation of these structures can be supplemented by special tests
De Quervain’s tenosynovitis
as described in the text
This is a stenosing tenosynovial inflammation of the first
Box 2 extensor compartment, which contains the abductor pollicis
longus (APL) and extensor pollicis brevis (EPB) tendons. Women
condition with a prevalence of 8% in the general population.1 are affected more commonly than men and patients typically
Patients typically present with pain on the radial side of the present between the ages of 30 and 50, with the gradual onset of
dorsum of the wrist, centred over the thumb CMC joint. Pain is pain over the first extensor compartment at the level of the radial
worst on activity. Weakness or difficulty with pinch may be styloid process.
marked and activities, such as opening bottles, cause difficulty. Firstly, look for swelling over the first dorsal compartment
Inspection may show swelling over the joint. ‘Squaring’ of the and palpate for point tenderness. Caution must be taken with the
base of the thumb may be seen in later disease, followed by nomenclature of the provocative tests for de Quervain’s e errors
adduction of the thumb metacarpal and compensatory hyperex- in how the tests are performed have propagated through the
tension of the metacarpophalangeal joint. With advanced disease literature and into text books.
this gives the characteristic ‘Z’ thumb appearance. Palpation is The Finkelstein manoeuvre4 is performed by the examiner
likely to elicit joint tenderness and crepitus. The range of motion grasping the patient’s thumb and quickly deviating the hand in
at the CMC joint is restricted. an ulnar direction, which provokes pain over the radial styloid
The grind test is performed by rotating the patient’s first (Figure 7a) when positive. The Eichhoff manoeuvre5 (which is
metacarpal whilst applying axial compression. The examiners often erroneously called Finkelstein’s) is performed by asking the

ORTHOPAEDICS AND TRAUMA 31:4 239 Ó 2017 Elsevier Ltd. All rights reserved.
 THE WRIST

Figure 3 Dorsal (left) and volar (right) wrist surface anatomy. CMC, carpometacarpal;
DRUJ, distal radioulnar joint; SL, scapholunate.

patient to clench their own thumb into a fist and then deviate in
an ulnar direction (Figure 7b). When positive this leads to pain,
which is relieved once the thumb is extended, even when the
wrist remains ulnarly deviated. Due to the passive nature of both
of these tests (i.e. the tendons of the first extensor compartment
are not active during the tests) other pathology of the radial
border of the wrist can also cause pain and give a false-positive
result.
The WHAT test6 (wrist hyperflexion and abduction of the
thumb) is an active test, which stresses the APL and EPB ten-
dons. The patient is examined with the wrist flexed, thumb
abducted and metacarpophalangeal and interphalangeal joints of
the thumb in extension. Resisted thumb abduction/extension is
then tested and a positive result is reported pain over the first
extensor compartment (Figure 7c). This isolates the tendons of
the first extensor compartment. Contrary to tests for base of

Figure 4 Normal range of motion of the wrist. Pronation 75 (a) and supination 80 (b) flexion 75 (c) and extension 75 (d) radial deviation 20
(e) and ulnar deviation 35 (f).

ORTHOPAEDICS AND TRAUMA 31:4 240 Ó 2017 Elsevier Ltd. All rights reserved.
 THE WRIST
Figure 5 The dart throwing movement. A composite movement of the wrist from supination-radial deviation-extension (left), to pronation-ulnar
deviation-flexion (right). This assesses functional wrist movement.
Sensitivity and specificity e definition and worked
example
Sensitivity e probability of a positive result in patients with the
disease (true positive rate) i.e. the probability of detecting the
disease if the patient truly has it.
Specificity e probability of a negative test in patients without
the disease i.e. correctly determining that they don’t have the
disease.
Example interpretation: A patient has radial sided wrist pain and
you suspect they have first carpometacarpal (CMC) joint arthritis.
You examine them with the grind test, which has 30% sensitivity
and 92% specificity.
C If the patient has first CMC joint arthritis, there is a 30%
chance the test will be positive
 i.e. 30% chance of testing positive if they do have first
CMC joint arthritis
 This means that even if the test is negative, the patient
may well still have first CMC joint arthritis (this test isn’t
very sensitive at detecting cases of first CMC joint
arthritis)
C If the patient does not have first CMC joint arthritis, there is a
92% chance the test will be negative
 i.e. 92% chance of test being normal if they don’t have
first CMC joint arthritis
 This means if the test is positive, there is a good chance
the patient has first CMC joint arthritis (the test is specific,
i.e. it is not usually positive in other wrist pathology)
Important note: Sensitivity and specificity alone cannot be used
to calculate the percentage chance of a patient who tests
positive actually having first CMC joint arthritis (positive
predictive value). This varies depending on how common first
CMC joint arthritis is in the patients being tested (i.e. the
prevalence)
Box 3
ORTHOPAEDICS AND TRAUMA 31:4
thumb arthritis, tests for de Quervain’s have high sensitivity but
low specificity. In other words, patients with de Quervain’s are
very likely to have a positive test, but patients with a positive test
do not necessarily have de Quervain’s tenosynovitis (Table 1).6
Radial styloid arthritis
Radial styloid arthritis is the first stage of scapholunate advanced
collapse (SLAC) wrist. Care must be taken to differentiate base of
thumb arthritis and de Quervain’s from this condition, as all have
point tenderness in a similar region. This should be done using
knowledge of surface anatomy in conjunction with the appro-
priate provocative tests.
Intersection syndrome
Intersection syndrome is a less common phenomenon caused by
inflammation at the point of crossover of the first (abductor
pollicis longus and extensor pollicis brevis) and second (extensor
carpi radialis longus (ECRL) and brevis (ECRB)) extensor com-
partments.7 It is associated with repetitive wrist extension and is
relatively more common in rowers and weight lifters.
Patients have point tenderness and swelling over the inter-
section, which can be palpated on the dorsal forearm 4 cm
proximal to Lister’s tubercle (refer to Figure 3). Some patients
will have crepitus on flexion and extension at the same point.
Wartenberg syndrome
Wartenberg syndrome is a rare compression neuropathy of the
superficial sensory branch of the radial nerve. The nerve is
compressed by a scissoring action of the brachioradialis and
ECRL tendons during forearm pronation. Patients present with
ill-defined dorsoradial wrist pain, paraesthesia or numbness.
These symptoms can be exacerbated by movements, which in-
crease traction on the nerve, including repetitive wrist flexion
and ulnar deviation.
Tinel’s sign is commonly positive, either over the radial sty-
loid (type 1) or just distal to the brachioradialis muscle belly,
which is 9 cm proximal to the radial styloid (type 2) or a com-
bination of the two (type 3). Pronation of the forearm with ulnar
deviation exacerbates symptoms.
There is an association with de Quervain’s tenosynovitis. This
is problematic because provocative tests for de Quervain’s
241 Ó 2017 Elsevier Ltd. All rights reserved.
 THE WRIST

Figure 6 Thumb adduction test. The examiner stabilizes the ulnar side of the patient’s wrist with one hand (a) and adducts the thumb by pressing
over the first metacarpal head (b).

tenosynovitis can also exacerbate the symptoms of Wartenberg (radial side of scaphoid affected early). Grip strength and pinch
syndrome e and this needs to be considered during assessment. strength are both reduced.
On examination a scaphoid non-union may be tender to axial
Radialevolar symptoms compression. The examiner palpates the scaphoid between their
thumb (on the scaphoid tubercle volarly) and index finger (in the
FCR tendonitis
anatomical snuffbox dorsally). If the patient is developing SNAC,
Flexor carpi radialis (FCR) tendonitis is a relatively uncommon
inspection may reveal swelling of the dorsoradial aspect of the
condition linked to repetitive wrist flexion. Pathologically it is
wrist related to a combination of osteophytes and focal synovitis.
characterized by inflammation within the tendon’s synovial
There will be tenderness to palpation of the radioscaphoid
sheath, which causes pain on the volar and radial aspect of the
articulation. Extension and radial deviation will be decreased
wrist.
and/or painful.
Look for swelling over the tendon (Figure 8). There is
tenderness to palpation over the volar and radial forearm along Carpal tunnel syndrome
the course of the FCR tendon at the level of the distal wrist Carpal tunnel syndrome is a constellation of symptoms and signs
flexion crease. The provocation manoeuvre is resisted wrist that result from median nerve compression within the carpal
flexion and radial deviation with palpation of the FCR tendon. tunnel, beneath the transverse carpal ligament. It is the most
common compressive neuropathy. It is associated with diabetes,
Scaphoid non-union
hypothyroidism, rheumatoid arthritis, pregnancy and amyloid-
In the early stages of this condition patients may present with
osis. The assessment of patients with suspected carpal tunnel
few or no symptoms. Over time, chronic non-union leads to
syndrome centres around the history, followed by an assessment
scaphoid collapse and progressive arthritis (scaphoid non-union
of median nerve sensory and motor function.
advanced collapse (SNAC) wrist). This occurs in a characteristic
Patients classically present with radial-sided hand pain and
pattern; firstly radial side of scaphoid and radial styloid, then
paraesthesia that wakes them from sleep. The numbness is in the
scaphocapitate arthrosis, and finally periscaphoid arthrosis.
distribution of the median nerve e the radial three and a half
However, the lunocapitate joint may remain relatively
digits. Clumsiness is a feature if the recurrent motor branch to
unaffected.
the thenar eminence is involved. Inspection may reveal thenar
Patients present with a history of progressive pain, stiffness
atrophy; test for weakness of resisted abduction. Altered sensa-
and weakness. They may or may not recall previous wrist
tion should be examined for in the median nerve distribution
trauma. There is a reduced range of wrist flexion and extension.
using graduated monofilaments.
The stiffness is most marked in extension and radial deviation
Tinel’s, Phalen’s and Durkan’s tests are often used in the
diagnosis of carpal tunnel syndrome. Tinel’s test is performed by
tapping over the patient’s median nerve at the distal wrist crease
and is positive if it provokes paraesthesia in the median nerve
Comparison of tests for first carpometacarpal joint distribution. Phalen’s test requires the patient to flex both wrists
arthritis and de Quervain’s disease to 90 for 60 seconds and is positive if this produces paraesthesia
in the median nerve distribution. Durkan’s pressure provocation
Test Sensitivity Specificity test requires the examiner to press over the patient’s carpal
tunnel with their thumb for 60 seconds and is positive if this
Grind 30e44% 92e97%
produces paraesthesia in the median nerve distribution. A com-
Traction shift 66.7% 100%
bination of wrist flexion (Phalen’s) with pressure applied (Dur-
Thumb adduction 95% 93%
kan’s) for 60 seconds (Figure 9) gives good sensitivity (96%) and
Point tenderness 94% 81%
specificity (80%).
Eichhoff test 89% 14%
Sensitivity and specificity values for a range of tests are shown
WHAT test 99% 29% in Table 2.8e10 There are many clinical tests for carpal tunnel
syndrome, but there are no gold standard diagnostic criteria e
Table 1

ORTHOPAEDICS AND TRAUMA 31:4 242 Ó 2017 Elsevier Ltd. All rights reserved.
 THE WRIST

Figure 8 Flexor carpi radialis (bottom of image) and flexor carpi

ulnaris (top of image) S indicates the scaphoid tubercle position, and
P indicates the position of the pisiform.

Figure 9 Testing for carpal tunnel syndrome with the wrists flexed.
Direct pressure is applied over the tunnel with the examiner’s thumb
for 60 seconds.

Comparison of tests for carpal tunnel syndrome

Test Sensitivity Specificity

Figure 7 a) Finkelstein’s test. The examiner grasps the patients thumb Tinel’s test 41e64% 56e99%
and quickly ulnarly deviates. The examiner stabilizes the wrist with Phalen’s test 59e85% 33e95%
their other hand. (b) Eichhoff’s test. The patient grips their own thumb Durkan’s test 42-89% 18e96%
in the palm and ulnarly deviates. The point of maximal pain is indicated Compression and flexion 96% 80%
by the examiner’s right index finger. (c) WHAT test. The patient’s wrist
is hyper-flexed, and the thumb is abducted. The examiner stabilizes Table 2
the wrist with one hand, and asks the patient to abduct and extend the
thumb against resistance.
Central symptoms
therefore the case definition varies. This has implications when Midcarpal instability
comparing quoted sensitivity and specificity for different clinical Midcarpal instability is a subtype of carpal instability non-
tests from different studies e there is a very wide range. dissociative (CIND). It is characterized by instability between
Abnormal clinical findings from provocative testing may be less the proximal and distal carpal row caused by extrinsic ligament
apparent in advanced disease.8 dysfunction or laxity. There is usually no history of trauma and
It is also important to consider alternative causes of the patients often have generalised ligamentous laxity.
symptoms, and one should always examine the patients elbow Patients present with subluxation, which may or may not be
and neck. It may not be possible to identify what nerve is affected painful, and complain of the wrist ‘giving way.’ They may have a
by the history alone, and the radial and ulnar nerves should also wrist clunk on certain movements when the wrist is under axial
be evaluated in the setting of suspected carpal tunnel syndrome. load. First, examine for signs of generalized ligamentous laxity.

ORTHOPAEDICS AND TRAUMA 31:4 243 Ó 2017 Elsevier Ltd. All rights reserved.
 THE WRIST
Figure 10 Lichtman’s test for midcarpal instability (see text for
description).
Try to bend the thumb to contact the patient’s forearm. The gap
averages 4.5 cm in 17-year-olds and increases with age.
Lichtman described the midcarpal shift test for midcarpal
instability. To perform this on the patient’s left wrist the exam-
iner first stabilises the patients pronated forearm with their right
hand. The examiner presses on the capitate with the left thumb
to apply a volarly directed force to the distal carpal row. This
pressure should be maintained, then the wrist is deviated in an
ulnar direction (Figure 10). The test is positive if there is a clunk,
which may or may not be painful. Beware that the patient may be
asymptomatic from their midcarpal instability and may have an
alternative source for pain.
Scapholunate dysfunction and SLAC wrist
The scapholunate ligament is essential for the maintenance of
carpal stability. Disruption of the ligament, from either an acute
injury or degenerative rupture, leads to abnormal wrist
biomechanics and ultimately advanced arthritis. A chronic
scapholunate ligament injury causes the scaphoid to flex and
the lunate to extend due to the unopposed extension force of the
triquetrum transmitted through an intact lunotriquetral liga-
ment. This results in dorsal intercalated segment instability
(DISI) and resulting abnormal forces across the radiocarpal and
Figure 11 Watson’s scaphoid shift test. Force is applied to the scaphoid tubercle as the
wrist is taken from ulnar (a) to radial deviation (b).
ORTHOPAEDICS AND TRAUMA 31:4
midcarpal joints. Progressive arthritis e SLAC wrist e is the
end result.
Patients with a scapholunate ligament deficiency present with
pain or clicking in the wrist and may have swelling over the
dorsal surface of the wrist and tenderness over the scapholunate
ligament interval, found just distal to Lister’s tubercle. Scaphoid
instability is demonstrated by Watson’s scaphoid shift test. This
provocative manoeuvre is performed by exerting a dorsally
directed load to the scaphoid tubercle as the wrist is taken from
ulnar to radial deviation (Figure 11). Dorsal displacement of the
scaphoid is noted, but the test is only considered positive if this is
associated with pain. The sensitivity is 16.7% and specificity is
88.5%.11 The low sensitivity potentially reflects the difficult
interpretation.
Patients with a SLAC wrist have focal tenderness, which
corresponds to their disease stage. Tenderness is initially limited
to the radial styloid, as discussed above. Subsequently, in stage
two and three disease the tenderness is more extensive along the
scaphoid facet of the distal radius and then involves the cap-
itolunate joint. The radiolunate joint is characteristically spared.
Tenderness is accompanied by a reduction in wrist range of
movement and weakness in grip strength.
Kienbo € ck’s disease
Osteonecrosis of the lunate, or Kienbo €ck’s disease, is a rare
condition that leads to progressive wrist pain and disability. Its
aetiology remains poorly understood, but vascular and me-
chanical factors have both been implicated.
Patients present with central wrist pain. Inspection reveals
swelling over the dorsal surface of the wrist and there is focal
tenderness over the lunate to palpation. A detailed understanding
of wrist surface anatomy is again important here. Patients have a
reduced range of motion in flexion and extension, with pain at
the end of range and there is also reduced grip strength on the
affected side.
Ulnaredorsal symptoms
Lunotriquetral instability
The spectrum of lunotriquetral (LT) ligament injury ranges from
partial tears with variable pain and weakness to complete
244 Ó 2017 Elsevier Ltd. All rights reserved.
 THE WRIST
dissociation with static collapse, causing a fork-like deformity of
the wrist and prominence of the distal ulna (advanced VISI
deformity). The dorsal intercarpal ligament may also be
damaged, which acts as a secondary restraint of the luno-
triquetral joint. Patients may or may not recall a hyperextension
injury to the wrist and present with ulnar sided pain that is worse
with pronation and ulnar deviation.
When the LT ligament is disrupted the lunate and scaphoid
flex and the triquetrum extends. This may be visible on inspec-
tion, as the carpus appears flexed compared to the distal radius.
Pain may be present on direct palpation of the joint.
The lunotriquetral ballottement test (Reagan’s test) is per-
formed by grasping the pisotriquetral unit between the thumb
and index finger of one hand and the lunate between the thumb
and index finger of the other (Figure 12). If the test is positive,
pain and increased anteroposterior laxity will be noted during
manipulation of the joint. It is highly specific, but has poor
sensitivity.11
DRUJ osteoarthritis and instability
A variety of acute wrist injuries can result in DRUJ instability,
which can then present with late symptoms, depending on how
the initial injury was managed. DRUJ dysfunction is a common
cause of ulnar-sided wrist pain and there will often be an asso-
ciated triangular fibrocartilage complex (TFCC) injury.
Patients with instability will usually have a history of injury
and present with pain, stiffness and clicking associated with
pronation and supination. Examine for a restricted range of
pronation and supination. DRUJ instability can be assessed with
the piano key test. The patient’s wrist is supported in pronation
and a force is applied to the head of the ulna by the examiner’s
thumb (Figure 13). The test is positive if the ulnar head returns
back to its normal anatomical position, similar to the movement
of a piano key when pressure is released.
Later, patients develop osteoarthritis of the DRUJ. There may
be deformity of the wrist or forearm visible on inspection,
resulting from incongruency of the DRUJ and subsequent
degeneration. Again, patients have pain and stiffness on prona-
tion and supination. The ulnar compression test is performed by
pressing the ulnar head onto the radius, thereby compressing the
DRUJ, producing pain when positive.
Figure 12 Regan’s test for lunotriquetral instability.
ORTHOPAEDICS AND TRAUMA 31:4
Figure 13 Piano key test for distal radioeulnar joint instability.
ECU tendonitis and instability
The tendon of extensor carpi ulnaris (ECU) runs through the
sixth extensor compartment on the dorsal surface of the wrist. A
spectrum of pathology can occur, ranging from tendonitis to
instability. Patients with ECU tendonitis have focal tenderness
over the tendon on the volar and ulnar aspect of the wrist. The
classically described provocation test is asking the patient to
perform resisted wrist extension and ulnar deviation. However,
this manoeuvre also loads the TFCC and lunotriquetral ligament
and compresses the distal ulna against the carpus. Consequently,
a false-positive finding can occur if the pathology is within these
areas of the wrist.
The ECU synergy test has been advocated to avoid the false
positive results associated with resisted wrist extension and
ulnar deviation. The test exploits the synergistic activation of
ECU with resisted thumb abduction. It is performed by resting
the patient’s elbow on an examination table and flexing their
elbow to 90 with the forearm in full supination. The examiner
palpates the ECU tendon with one hand whilst the other grasps
the patient’s thumb and middle finger. The patient then abducts
the thumb against resistance. ECU muscle contraction is
confirmed by appreciating bowstringing of the tendon. A positive
finding includes the reproduction of pain over the dorsal and
ulnar aspect of the wrist.12
ECU subluxation results from attenuation or rupture of the
ECU subsheath. On examination, the tendon subluxes with su-
pination and reduces into its groove during pronation. This can
be associated with a painful snap.
Ulnarevolar symptoms
TFCC tear
The TFCC is composed of the dorsal and volar radioulnar lig-
aments, a central articular disc, the ulnar collateral ligament,
the ECU subsheath and the origin of the ulnolunate and ulno-
triquetal ligaments. Injuries to the complex can be classified
into either type 1 (traumatic) or type 2 (degenerative), the latter
of which is associated with positive ulnar variance and ulno-
carpal impaction.
Patients have a positive fovea sign on examination. This is
performed by palpating the soft spot between the ulnar styloid,
the FCU tendon, the volar surface of the ulnar head and the
pisiform, with pain representing a positive test. The ulnar grind
test is conducted with the wrist held in dorsiflexion and the
245 Ó 2017 Elsevier Ltd. All rights reserved.
 THE WRIST
Figure 14 Nakmura’s ulnar stress test for ulnar sided wrist pathology. The ulnarly deviated and pronated wrist is axially loaded from extension
(a) into flexion (b).
forearm fixed. Axial load is applied and the wrist is rotated and
deviated in ulnar direction. The test is positive when pain and
crepitation occurs during this manoeuvre. The correlation be-
tween arthroscopy findings and clinical tests is generally low for
both tests; they demonstrate poor specificity.11,13
Ulnocarpal abutment syndrome
Ulnocarpal abutment syndrome is caused by excessive impact
stress between the ulna and carpal bones (mainly the lunate). It
occurs in patients with a positive ulnar variance, which can be
seen in the setting of scapholunate dissociation, TFCC tears and
lunotriquetral ligament tears. Careful examination of these
structures needs to be undertaken in any patient with ulnocarpal
abutment.
Ask the patient about previous wrist injuries that lead to
positive ulnar variance, such as distal radius fracture. They may
complain of dorsoulnar sided wrist, pain which is worse on axial
loading and ulnar deviation. Examination should assess the
DRUJ and TFCC. Nakmura’s ulnar stress test was designed to
detect abutment, but may also be positive with TFCC injury. The
patient’s wrist is first deviated in an ulnar direction and pro-
nated. The examiner then axially loads the wrist, whilst flexing
and extending it (Figure 14). A positive test produces pain. This
test is good at detecting patients with ulnar sided wrist pathol-
ogy, but is not good at delineating the exact cause (it has low
specificity).14
Flexor carpi ulnaris tendonitis
Flexor carpi ulnaris (FCU) tendonitis is a degenerative tendonosis
of the FCU tendon. It differs from FCR tendonitis because the FCU
does not have a synovial sheath at the wrist and hence is more
similar in pathological terms to tennis elbow. Tendon calcifica-
tion may also occur.15
Inspection may reveal swelling and/or erythema overlying the
tendon.15 The patient will have tenderness over the FCU
approximately 3 cm proximal to the pisiform and pain on resisted
flexion and ulnar deviation of the wrist that is localized to the
FCU tendon (Figure 8).
This condition should be differentiated from the more com-
mon pisotriquetral osteoarthritis, were the pain is maximal when
compressing directly over the pisiform.
ORTHOPAEDICS AND TRAUMA 31:4
Ulnar nerve compression
Ulnar nerve compression at the wrist is uncommon and symp-
toms and signs of ulnar neuropathy should prompt examination
of the elbow, brachial plexus and neck, since compression in the
cubital tunnel or at the C8-T1 nerve roots is more common. In or
near Guyon’s canal (through which the ulnar nerve transits into
the hand, between the pisiform and hook of hamate) it divides
into a superficial sensory and a deep motor branch. Therefore,
signs and symptoms vary depending on which part of the nerve
is compressed. Compression can be caused by hook of hamate
fractures (does the patient have a history of trauma?) and
ganglia, which give rise to point tenderness over Guyon’s canal.
Ulnar artery aneurysm or thrombosis can cause an isolated
compression of the superficial sensory branch. Altered sensation
in the ulnar nerve distribution, wasting of the hypothenar
eminence and wasting of the interosseous muscles should alert
the examiner towards ulnar nerve compression. A detailed
neurological examination should be performed.
Pisotriquetral arthritis
Degenerative osteoarthritis of the joint between the pisiform and
the triquetrium leads to pain deep to the hypothenar eminence.
The pisiform is the most ulnar and volar carpal bone and is a
sesamoid within the FCU tendon. It can be palpated by tracing
the FCU tendon distally into the palm. Patients present with ulnar
pain in the palm, exacerbated by direct compression and wrist
flexion (such as often occurs when playing racquet sports).
Clinically, there will be tenderness on direct compression of the
joint. Note that even in the normal wrist direct pressure over the
pisiform bone can be uncomfortable.
Conclusion
By dividing the wrist up into five zones as described, a system-
atic approach to the clinical examination is facilitated for the
wide range of pathologies that occur in this small anatomical
space. The zone in which the pain occurs should be the corner-
stone of the thought process from which the examination is
tailored. By developing a working diagnosis based on a thorough
history and examination, the chances of identifying the correct,
clinically relevant pathology are much increased and, depending
246 Ó 2017 Elsevier Ltd. All rights reserved.
 THE WRIST

on the examination findings, treatment can be planned subject to 8 Mondelli M, Passero S, Giannini F. Provocative tests in different
confirmatory radiological or other testing. History and clinical stages of carpal tunnel syndrome. Clin Neurol Neurosurg 2001;
examination are pivotal to the identification of what is actually 103: 178e83.
troubling the patient and hence developing the correct manage- 9 D’Arcy CA, McGee S. The rational clinical examination. Does this
ment strategy. A patient have carpal tunnel syndrome? J Am Med Assoc 2000; 283:
3110e7.
10 Wiesman IM, Novak CB, Mackinnon SE, Winograd JM. Sensitivity
REFERENCES
and specificity of clinical testing for carpal tunnel syndrome. Can J
1 Haara MM, Heliovaara M, Kroger, et al. Osteoarthritis in the car-
Plast Surg J Can Chir Plast 2003; 11: 70e2.
pometacarpal joint of the thumb. Prevalence and associations
11 Ruston J, Konan S, Rubinraut E, Sorene E. Diagnostic accuracy of
with disability and mortality. J Bone Jt Surg Am 2004; 86eA:
clinical examination and magnetic resonance imaging for common
1452e7.
articular wrist pathology. Acta Orthop Belg 2013; 79: 375e80.
2 Gelberman RH, Boone S, Osei DA, Cherney S, Calfee RP. Tra-
12 Ruland RT, Hogan CJ. The ECU synergy test: an aid to diagnose
peziometacarpal arthritis: a prospective clinical evaluation of the
ECU tendonitis. J Hand Surg 2008; 33: 1777e82.
thumb adduction and extension provocative tests. J Hand Surg
13 Schmauss D, Pohlmann S, Lohmeyer JA, et al. Clinical tests and
2015; 40: 1285e91.
magnetic resonance imaging have limited diagnostic value for
3 Choa RM, Parvizi N, Giele HP. A prospective case-control study
triangular fibrocartilaginous complex lesions. Arch Orthop Trauma
to compare the sensitivity and specificity of the grind and traction-
Surg 2016; 136: 873e80.
shift (subluxation-relocation) clinical tests in osteoarthritis of the
14 Nakamura R, Horii E, Imaeda T, et al. The ulnocarpal stress test in
thumb carpometacarpal joint. J Hand Surg Eur Vol 2014; 39:
the diagnosis of ulnar-sided wrist pain. J Hand Surg Edinb Scotl
282e5.
1997; 22: 719e23.
4 Finkelstein H. Stenosing tendovaginitis at the radial styloid pro-
15 Torbati SS, Bral D, Geiderman JM. Acute calcific tendinitis of the
cess. J Bone Jt Surg 1930; 12: 509e40.
wrist. J Emerg Med 2013; 44: 352e4.
5 Eichhoff E. Zur pathogenese der Tendovaginitis stenosans. Bruns
Beitrage Z Klin Chir 1927; CXXXIX: 746e55.
6 Goubau JF, Goubau L, Van Tongel A, et al. The wrist hyperflexion
and abduction of the thumb (WHAT) test: a more specific and Acknowledgements
sensitive test to diagnose de Quervain tenosynovitis than the
Eichhoff’s Test. J Hand Surg Eur Vol 2014; 39: 286e92. We would like to extend our gratitude to Pamela Palphreyman for
7 Sato J, Ishii Y, Noguchi H. Clinical and ultrasound features in proofreading the article and to Olivia Mennie for helping with the
patients with intersection syndrome or de Quervain’s disease. hand examination figures.
J Hand Surg Eur Vol 2016; 41: 220e5.

ORTHOPAEDICS AND TRAUMA 31:4 247 Ó 2017 Elsevier Ltd. All rights reserved.